=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386761906
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AUDREY SHEILAH AMDURSKY L.C.S.W.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 123 E 64TH ST A
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10021-7059
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-737-5151
-----------------------------------------------------
Fax | 212-486-7133
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 123 E 64TH ST A
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10021-7059
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-737-5151
-----------------------------------------------------
Fax | 212-486-7133
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | R027540
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------